Provider Demographics
NPI:1285359497
Name:DEAN, MADISON (BCBA, LBA)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:DEAN
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 CLEAR LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-7242
Mailing Address - Country:US
Mailing Address - Phone:903-522-9162
Mailing Address - Fax:
Practice Address - Street 1:2912 WARREN AVE
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8862
Practice Address - Country:US
Practice Address - Phone:337-661-4041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-674103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst